Associate professor Steven Howard, MD, is well known for his research on fatigue and sleep deprivation, especially as it relates to health-care professionals. Howard’s previous research has shown the benefit of napping on emergency room doctor and nurses’ performance, the implications of fatigue among clinicians and the potential risks of daytime sleepiness among resident physicians.

Below he discusses how fatigue negatively affects performance, the role cultural beliefs or societal pressures play in increasing the prevalence of sleep deprivation in our country and how organizations and professional societies can promote sleep as a priority among health-care professionals.

What happens, physiologically, when a person’s sleep balance is disturbed?

Individuals have a genetically determined sleep need, which for adults is around eight hours. Most of us get far less than this. If you get less sleep than needed, then you develop what is called a “sleep debt.” The only way to repay a sleep debt is by obtaining adequate sleep. People often don’t repay sleep debts for many reasons including that some believe sleep is just “lost time.” Individuals with a sleep debt will often have impaired performance and negative moods, and they are prone to falling asleep at work and elsewhere.

Your research has shown that a short nap for doctors and nurses working night shifts improved their mood and alertness level. The findings prompted the Veterans Affairs Palo Alto Health Care System to implement an official napping program in 2006. What have you learned about the benefits of napping for health-care professionals since the program began?

Naps improve alertness and performance in both lab and field studies. A number of lessons have been learned by trying to implement napping in the real world of the hospital. Many people will find excuses not to nap because of the negative associations that this behavior has in our society (i.e. napping is for wimps). It will take a shift in thinking to make napping an acceptable practice, and I believe that we have started to see this in local pockets at the Veterans Affairs Palo Alto Health Care System. Nurses in one of our critical care areas have been successfully utilizing this strategy since the program was implemented. The biggest hurdle that we overcame was that it is now OK to nap on your breaks, which is a major shift from the professional environment of five years ago when people could be fired for sleeping on the job. Of course, we still have a long way to go.

You’ve mentioned that naps are often discouraged and considered “lazy” behavior. What role have cultural beliefs or societal pressures played in increasing the prevalence of sleep deprivation in the United States?

In addition to what I’ve mentioned above, we live in a 24/7 society and there are many things that vie for our attention. Sleep is easily usurped by these interesting things. American culture is obviously tied into this. We reward ourselves for staying up all night studying or making it through a difficult call when in actuality we might be hurting ourselves or our patients. I am on record as saying that we could limit work hours to 20 hours per week but people would still come to work impaired. I believe it is a professionalism issue that we should come to work prepared not impaired.

How can organizations and professional societies promote sleep as a priority among health-care professionals?

Some professional societies have advocated guidelines that promote healthy sleep and work. Anesthesia societies in the United Kingdom, Australia and New Zealand are on record with such work. This is still in its infancy in the United States where there are many other important issues to address. For example, as a resident on June 30 I might not have any incentive to work longer than what is allowed by the Accreditation Council for Graduate Medical Education. But when I am done with residency training on July 1 I am likely more willing to take on an extra case or see an additional patient because now I am getting paid to do so. This financial incentive combined with the fact that I could have a hefty medical school debt motivates me in a different manner.

If work environments don’t provide napping programs or take other measures to prevent sleep deprivation, what steps can physicians and nurses, as well as other busy professionals, take to make sure fatigue isn’t compromising their performance?

The most important thing you can do is make sleep a priority in your life. Most people cannot use caffeine to adequately countermeasure fatigue because continuous use has made them tolerant. So try to use caffeine strategically. If you’re really tired, try to sleep before you get the car to drive home or take a taxi home. If you see a colleague falling asleep, then suggest the individual take a nap or offer them a ride home. Being awake for 24 hours has the same effect as being legally drunk. If you saw someone who was drunk, wouldn’t you take away his keys? Same idea.